Instructions: If Applicable, Submit This Form with Animal Use Protocol (AUP)

Supplemental Hazardous Materials, Risk Assessment

Instructions: If applicable, submit this form with Animal Use Protocol (AUP). (PLEASE SINGLE CLICK ON SHADED BOXES TO TYPE)

1.Description of hazardous material

a. Hazard (fill in applicable information):

Chemical (name) Route of toxicity (e.g. inhalation) Type of toxicity (e.g. irritant) Biohazard (name) Route of infection (e.g. inhalation) Biohazard level (e.g. BSL-1) Radioisotope (name) Route of administration Physical hazard (e.g. UV light) Route of administration Other (describe) Route of administration

b. Description of hazardous material: (form upon receipt, solubility, volatility, vehicle, etc.):

c. If applicable, Manufacturer: Product #:

d. Where will the material be stored prior to use (room, refrigeration, etc.)?

e. Submit a material data sheet if commercially available (submit as an e-mail attachment).

2.Proposed use of hazardous material in animals

a. Animal species to be dosed:

b. Proposed work location:

c. Dose per animal:

d. Route of delivery:

e. Treatment schedule:

f. Time treated animals will be maintained:

g. Number of animals to be treated for each experiment: 3.Fate of hazardous material (where does the compound go after dosing the animal?)

a. Route of excretion:

b. What is excreted:

c. Percent excreted:

d. Where is the hazard? How long is it present? Describe where the hazard exists and how it should be handled:

4.Institutional approvals for using hazardous materials

a. Institutional Biosafety Committee (IBC) a.i. IBC Protocol Number: a.ii. Date of IBC approval:

b. Radiation Safety Committee (RSC) b.i. Date of RSC approval:

5.Exposure Risk Management

a. Preparing hazardous material a.i. Where will hazardous material be prepared (lab, room, fume hood, BSC)?

a.ii. Lab door signage will read:

a.iii. Required PPE for preparation:

a.iv. Clean-up procedures:

a.v. Waste disposal procedures:

b. Exposing animals to hazardous material

b.i. Where in vivaria will animal work be conducted?

b.ii. Animal room signage will read:

b.iii. Required PPE for research staff:

b.iv. Clean-up procedures:

b.v. Waste disposal procedures:

c. After exposing animals to hazardous material c.i. Time frame (how long will animals be kept following exposure):

c.ii. Animal room signage will read:

c.iii. Required PPE for research staff:

c.iv. Required PPE for LAB staff:

c.v. Cage changing frequency:

c.vi. Bedding disposal procedure: c.vii. Carcass disposal procedure:

c.viii. Waste disposal procedure:

d. Termination of hazardous experiment in animals d.i. Time frame (how long will hazard be present):

d.ii. Animal room signage will read: d.iii. Required PPE for research staff: d.iv. Required PPE for LAB staff:

d.v. Cage changing frequency: d.vi. Bedding disposal procedure: d.vii. Carcass disposal procedure:

d.viii. Waste disposal procedure:

e. Action to take if you have an accidental exposure to hazardous material e.i. Needle stick, other sharp:

e.ii. Skin or mucous membrane exposure: e.iii. Where to seek medical attention:

e.iv. File an accident report:

f. Drugs, antidotes, or immunizations available to hazardous material f.i. Drugs and dosage: f.ii. Antidotes and dosage:

f.iii. Immunization:

6.For IACUC use only: date and name of person reviewing hazard information including comments

a. Environmental Health & Risk Management:

b. Biosafety Officer:

c. Occupational Health and Safety: